Patient Assessment Summary Sheet for Trauma Cases

1. Step 1:

a. Receiving Nurse:

• Measure vital signs and perform an ECG.

• Transfer the patient to the designated care area based on triage severity.

b. Examining Physician:

• Required paraclinical tests and initial treatment:

  • Blood tests, X-rays, ultrasound, CT scans: Depending on the specific case.

  • Medication administration, wound care, blood transfusion, and continuous monitoring: Depending on the specific case.

c. Staff Nurse:

• Collect blood samples for testing.

• Administer medications.

• Perform wound dressing and local hemostasis.

• Monitor the patient.

d. Transport/Facility Nurse:

• Escort the patient for X-rays, ultrasound, and CT scans.

• Wait for paraclinical results.

2. Step 2: Full Paraclinical Results Available

a. If the diagnosis is clear, patient condition is stable, and responsive to treatment:

• Discharge – Issue outpatient prescription – Schedule follow-up at the specialty clinic.

b. If the diagnosis is unclear, patient condition is unstable, or unresponsive to treatment:

• Perform additional appropriate paraclinical tests and provide treatment according to the patient's condition.

• Consult relevant specialist physicians when necessary.

• Continue medical treatment.

• Post-specialty consultation:

  • If the patient has indications for hospital admission or intervention: -> Await admission to specialized wards. -> Transfer to the operating room for surgery. -> Transfer to the endovascular intervention unit.

  • If the patient does not have indications for admission: -> Discharge (when stable).

The information above is for reference purposes only and is not intended as medical advice. Please contact your doctor for detailed medical consultation.